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Background <p>Osteoporosis is a chronic skeletal disorder characterized by reduced bone mineral density and disrupted bone microarchitecture, affecting over 200&#xa0;million individuals worldwide. The lumbar spine, containing the largest volume of metabolically active trabecular bone, is particularly vulnerable to osteoporotic degeneration and compression fractures. This narrative review examines recent advances in imaging modalities for lumbar spine osteoporosis assessment, emphasizing the diagnostic utility and emerging clinical applications of ¹⁸F-sodium fluoride (NaF) positron emission tomography/computed tomography (PET/CT). A comprehensive narrative review was conducted, synthesizing findings from pivotal studies investigating conventional imaging methods and newer PET-based technologies for osteoporosis evaluation. Particular focus was given to studies utilizing quantitative and kinetic PET biomarkers for assessing bone metabolic activity with ¹⁸F-NaF.</p> Main body <p>While dual-energy X-ray absorptiometry (DXA) remains the clinical standard for bone mineral density assessment, it has significant limitations including poor spatial resolution, lack of three-dimensional capability, and inability to differentiate cortical from trabecular bone. In contrast, ¹⁸F-NaF PET/CT demonstrates superior image quality, rapid tracer kinetics, and quantitative assessment of regional osteoblastic activity. Studies show strong correlations between ¹⁸F-NaF uptake and bone turnover markers, mineral density measurements, and therapeutic response. Kinetic modeling approaches provide detailed insights into bone remodeling dynamics, supporting personalized treatment planning and prognostic assessment. Diagnostic performance studies report area under the receiver operating characteristic curves as high as 0.96 for osteoporosis detection when evaluated against DXA-derived BMD, though no study has yet compared both modalities against an independent gold standard such as fracture outcomes.</p> Conclusion <p>¹⁸F-NaF PET/CT offers optimal clinical applications for early treatment response monitoring, evaluation of patients with discordant clinical risk and DXA findings, pre-surgical assessment in patients with borderline bone density, and investigation of complex metabolic bone disorders. Ideally, ¹⁸F-NaF PET/CT should be utilized in a complementary fashion to DXA. Primary barriers to clinical adoption include cost, limited accessibility, and absence of standardized kinetic modeling protocols. Future research should focus on establishing reference ranges across age and sex demographics, validating fracture prediction models, and determining cost-effectiveness thresholds for specific clinical scenarios such as high-risk patients with discordant DXA and fracture history.</p>

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The emerging role of ¹⁸F-NaF PET/CT in osteoporosis: an emphasis on its application for the evaluation and management of lumbar spine osteoporosis

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2026年4月29日

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  • Jaskeerat Gujral,
  • Om H. Gandhi,
  • Amir A. Amanullah,
  • Mert Marcel Dagli,
  • Shashi B. Singh,
  • Cyrus Ayubcha,
  • Thomas J Werner,
  • Mona-Elisabeth Revheim,
  • William C. Welch,
  • Abass Alavi

摘要

Background

Osteoporosis is a chronic skeletal disorder characterized by reduced bone mineral density and disrupted bone microarchitecture, affecting over 200 million individuals worldwide. The lumbar spine, containing the largest volume of metabolically active trabecular bone, is particularly vulnerable to osteoporotic degeneration and compression fractures. This narrative review examines recent advances in imaging modalities for lumbar spine osteoporosis assessment, emphasizing the diagnostic utility and emerging clinical applications of ¹⁸F-sodium fluoride (NaF) positron emission tomography/computed tomography (PET/CT). A comprehensive narrative review was conducted, synthesizing findings from pivotal studies investigating conventional imaging methods and newer PET-based technologies for osteoporosis evaluation. Particular focus was given to studies utilizing quantitative and kinetic PET biomarkers for assessing bone metabolic activity with ¹⁸F-NaF.

Main body

While dual-energy X-ray absorptiometry (DXA) remains the clinical standard for bone mineral density assessment, it has significant limitations including poor spatial resolution, lack of three-dimensional capability, and inability to differentiate cortical from trabecular bone. In contrast, ¹⁸F-NaF PET/CT demonstrates superior image quality, rapid tracer kinetics, and quantitative assessment of regional osteoblastic activity. Studies show strong correlations between ¹⁸F-NaF uptake and bone turnover markers, mineral density measurements, and therapeutic response. Kinetic modeling approaches provide detailed insights into bone remodeling dynamics, supporting personalized treatment planning and prognostic assessment. Diagnostic performance studies report area under the receiver operating characteristic curves as high as 0.96 for osteoporosis detection when evaluated against DXA-derived BMD, though no study has yet compared both modalities against an independent gold standard such as fracture outcomes.

Conclusion

¹⁸F-NaF PET/CT offers optimal clinical applications for early treatment response monitoring, evaluation of patients with discordant clinical risk and DXA findings, pre-surgical assessment in patients with borderline bone density, and investigation of complex metabolic bone disorders. Ideally, ¹⁸F-NaF PET/CT should be utilized in a complementary fashion to DXA. Primary barriers to clinical adoption include cost, limited accessibility, and absence of standardized kinetic modeling protocols. Future research should focus on establishing reference ranges across age and sex demographics, validating fracture prediction models, and determining cost-effectiveness thresholds for specific clinical scenarios such as high-risk patients with discordant DXA and fracture history.